MU Attestation - Training Camp or the Real McCoy?

Many Eligible Providers are wrapping up their initial 90-day Meaningful Use demonstration period today and will attest to its successful completion early in the New Year. I want to wish you every success with that and sincerely hope that your investment of time, effort and dollars pays off in spades.


I also want to offer encouragement for those whose demonstration period didn't unfold quite as expected. You may already know this to be the case, or you may learn it through an Attestation that proves not to be acceptable. In either case, take heart.

• First, understand you are still far ahead of the pack. The fact that you got started and are even in the game is commendable.
• Second, think of your experience to date as "training camp" for your team. You got in shape for the real season, which can start as soon as January 1st. Going into 2012, you are considerably more ready and will move through your demonstration period in much better shape.
• Third, remember you are eligible for as much in 2012 as in 2011. There's no penalty associated with a later start unless you're in the same position at this same time next year. In fact, you may even gain from a 2012 start. For example, if your Medicare billings were below $2,000 per month and you've been building up to a higher volume, you may reach the maximum Year 1 incentive payment of $18,000 (75% of $24,000).
• Fourth and last, be reminded that you may start your demonstration period any time after January 1st.  It must be a continuous 90 days and also continue thereafter 365 day per year. Your deadline to get the maximum in incentive payments is October 1, 2012.

Wishing you a very prosperous 2012.


Alistair Jackson, M.Ed. 

I told you I was sick!

I once heard a great story about an elderly lady who didn't say much, certainly didn't complain much but her epitaph read, "I told you I was sick!" I'm hoping I don't have to write on my epitaph, "I told you it was about eye care!"


Vision Monday's December 21 article, "Fed Propose Health Care Reform's Essential Health Benefits Cover Routine Eye Exams and Corrective Lenses" should encourage every ECP, particularly all who care about pediatric vision services. It should also spur us on to action. Public comments are due by Jan. 31, 2012 and can be sent via email to EssentialHealthBenefits@cms.hhs.gov. 


Alistair Jackson, M.Ed.

So you wanted simple?

A comment we hear often from software seekers is, "I just want something simple". And we've all heard it said, "Be careful what you ask for ... you might just get it." In health IT, you certainly can get just about anything you ask for.


Let me ask a question in return. Is eye care a simple business? Call me naive but I can't think of a more sophisticated business than eye care. People ask me all the time what I do. It's no easy elevator speech to sum up scheduling and recalls, insurance and patient billing, scanning and barcoding, glasses and contacts, pre-test and exams, imaging and drawing, e-RX and ARs, opticianry, optometry and ophthalmology in one fell swoop. Ding. Third floor.


So what's my point? Well, when you go EHR shopping, be careful what you ask for. While software architects understand the need to hide complexity from end users, "simpler" may be the more appropriate word. But, lest I reduce the issue to mere semantics, the real point is not to expect simple solutions for a highly sophisticated business. Your practice will not be well served by free, inexpensive or simplistic solutions. You'll get what you pay for.


Mind if I share some more search tips?

• Software that wasn't built for eye care is not adequate for eye care. You can't bolt on an optical module for example. If inventory management wasn't part of the original design, it's just not that simple to add it in to your system's workflow.
• Eye care is second only to radiology in its volume of imaging. Think of your instrument suppliers when you ask about doing your eye exam on a mobile device, and remember that the MDs who are making it all sound so simple probably don't have to worry about fundus cameras, phoropters and OCTs.
• You're looking for a 20 year not a 2 year solution, right? So think ahead, way ahead. Look under the hood for a technology platform that will go the distance. Clinical Decision Support (CDS) is going to be the mantra of Stage 3 Certification, so find a software solution that shows true promise in that department. You can't bolt on CDS any more than you can bolt on an optical module. For more on CDS, read Part 5 of Behind the Stimulus Program, the Eye Care Opportunity in Health Care Reform.

Alistair Jackson, M.Ed.

Pioneering the Medical Home Model

We are about to get our first look at the Medical Home model. Accountable Care Organizations (ACOs) are umbrella organizations that include multiple teams of providers organized through the Medical Home model of care delivery, a model developed to provide better and coordinated care for the chronically ill, and to lower the cost of care through information sharing. 


On Monday December 19, HHS Secretary Kathleen Sebelius announced that 32 leading health care organizations would band together to participate in a new Pioneer Accountable Care Organizations initiative. The Pioneer initiative will encourage primary care doctors, specialists and hospitals to provide better, more coordinated care for people on Medicare, a program that could save $1.1 billion over the next five years. The Pioneer ACO package includes increased compensation for delivery of better care, testing of innovative payment models, coordination with private payers, and a reduction of costs for Medicare. The Pioneer ACO is specifically designed for groups of providers with experience working together to coordinate better care for patients, that now familiar mantra of "improved patient outcomes".

Now what does this have to do with the ophthalmic community? As my colleague Alistair Jackson noted in his December 19 post, we can see the future for optometry by looking outside the profession. The Medical Home model is our future and we need to learn the rules of the game. Primary care physicians will need to have their diabetic patients seen by eye care specialists. Hypertensive patients and a host of other types of patients will need eye care.  Optometry will solidify its position in the referral process by referring obese, at-risk patients to the Medical Home. Relationships will be built and optometry will be viable in the future. For those of us who have been around long enough to remember Medicare parity in the 1980s, this is not just more of the same. It doesn't automatically apply across the board. Optometrists need to be individually proactive in using every tool at their disposal to leverage their way into these networks. It can be done and, yes, there are model practices in the profession already showing us the way.   

Chuck Haine, O.D., M.S.

Eye Care is Transforming Too (Part 3 of 3)

(Continued from Part 2) By seeing what is being done to expand the capability of EHRs to truly raise the bar in improving patient outcomes, we begin to get a better appreciation of how all the different elements of health care reform fit together. The problem with the process we looked at in part 2 is that, today, there is no comprehensive list of medications with ocular side effects structured to be utilized by an EHR. At EMRlogic, however, we have teams of providers scanning professional literature and every other available source to build this much-needed list of medications with ocular side effects. In a perfect world, this list should be maintained by a reputable repository – perhaps an eye care registry – that providers can depend on for accuracy. We are working on this process now. There needs to be a clear and concise way for newly identified meds with ocular side effects to be reported so any medication not previously reported can be easily reported by any provider.

Aside from this need and many others like it, despite gaps in our health care ideology, as a provider today, I can be preparing for health care reform. Using an EHR that is designed for and continues to prepare for health care reform changes, collaborating with the supplier and other users of that EHR, is the key to the cultural transformation needed to ensure our practices meet the new needs in our rapidly changing health care delivery system.

Jim Grue, O.D.

Eye Care is Transforming Too (Part 2 of 3)

(Continued from Part 1) The Medical Home delivery model is structured around a formalized group of caregivers who collaborate and share patient health information and treatment goals on a particular patient. Numerous studies have shown that patient outcomes  improve for chronic conditions when this model is followed. One of the reasons for the improved outcomes is because the team shares expertise, experience and responsibilities in addition to patient health information. Understanding this, we can now start analyzing  the roles and contributions that make such a team successful. The obvious question for eye care is, “What will an ECP be expected to contribute to this team approach?”

One reasonable expectation is that the ECP would inform the team of an ocular side effect of any medication prescribed to the patient by any team member. 

Think of the challenge that presents to an individual provider using a paper record. It means the provider has to know, research or find the ocular side effect of potentially every medication on the market! A daunting task at best. If we look at it from a collaborative, systems approach, we see a completely different thing. In fact, we find that at least one eye care EHR already offers a functional solution and is leading a collaborative process to expand and strengthen this capability.

From a systems approach, here is what is already in place, as well as what is necessary to expand this ability for our profession:

1)      We as providers are already expected to be utilizing e-prescribing, which gives us access to more accurate lists of the medications our patients are on. Medical Home teams are required to use e-prescribing.

2)      When e-prescribing is completed, the hosting EHR downloads a list of all the medications the patient is on.

3)      The EHR needs to scan those medications and identify the ones with reported ocular side effects. At least one eye care EHR is already doing this. A warning containing the specific ocular side effect appears automatically, alerting the provider.

4)      The EHR creates an automatic report back to the Medical Home team inform each member that the side effects were evaluated and whether they were or were not present for this patient. (Continued in Part 3)

Jim Grue, O.D.

Eye Care is Transforming Too (Part 1 of 3)

In his December 6 post (What are you doing about Health Care Reform? Part 2), Alistair finished with a very important point: eye care providers (ECPs) who are not acting now are losing ground on “survive and thrive” issues. Throughout medicine, we see organizations and providers redefining their roles, leading a cultural transformation in the fundamental way health care is delivered.  Many of these changes are based on a changing health care delivery system structured around Accountable Care Organizations (ACO’s) and other team delivery concepts.  There are a number of team delivery models functioning but the ACO model based on the Medical Home structure is rapidly dominating the market. For ECPs not to lose ground on key survive and thrive issues, it is important to understand what preparatory steps are needed right now. 

I see four ways ECPs are responding to this challenge:

1)      Many are not even aware of the changes occurring and, therefore, are not acting

2)      Some see changes taking place in health care but the topics are so daunting and confusing on the surface, they don’t know what to do, therefore end up doing little or nothing

3)      Some providers are reacting to the obvious changes, such as the incentives to begin using a certified EHR, thinking they are adequately preparing without looking any deeper

4)      A small number of ECPs - a rapidly growing group – are analyzing and collaborating to create true solutions that lead eye care to a level of involvement in health care reform that not only maintains our current role but, further, expands our value within the overall health care system.

Let me give you an example of what some providers and organizations are doing in this fourth group. (Continued in Part 2)

Jim Grue, O.D.

To understand eye care, look outside!

Look outside! Outside eye care, that is. In the early days of the health care reform movement, I heard a number of speakers qualify their comments saying, "I don't have a crystal ball." The implication was no one could really know where this was all going. There were many unknowns, yes, especially if you were trying to understand by looking inside eye care. The elusive crystal ball became something of a mantra for leaders inclined to wait and see. 

Medicare's December 15 press release, "CMS announces first results for program to improve care for dialysis patients" is another great example of how we can understand health care reform implications for eye care by looking outside eye care. Some quotes from the press release are instructive.

The Centers for Medicare & Medicaid Services (CMS) today released the first results for a new Federal pay-for-performance or “value-based purchasing” program for dialysis facilities that is designed to give facilities payment incentives to improve the quality of care furnished to patients diagnosed with End-stage Renal Disease (ESRD).  Nearly 70 percent of dialysis facilities that were evaluated under the program will receive no payment reduction in payment year (PY) 2012, while the remaining 30 percent will receive reductions ranging from 0.5 percent to 2.0 percent depending on their final performance scores.
“The real purpose of value-based purchasing is to raise the bar on quality and that’s exactly what CMS is aiming to do for Medicare patients who have ESRD,” said CMS Acting Administrator Marilyn Tavenner. “This is one of many efforts CMS is making to drive quality improvement in all settings in communities across the country.”

What are our eye care takeaways from this announcement?

1. Let's admit that pay-for-performance is another of the key concepts of health care reform that has fallen on deaf ears in the eye care profession. Then let's start taking it seriously.

2. Let's understand that the Feds are serious about introducing pay-for-performance programs not only for renal diseases but for "all settings in communities across the country", and that that includes eye care.

3. Let's start putting pressure on the eye care profession to anticipate the eye care diseases likely to become pay-for-performance candidate programs and then begin developing the quality measures that make sense for eye care. 

4. Knowing that 'this too shall come' and, regardless of what happens at the national level, let's get ready with local, even individual initiatives. 

5. Once again, let's come back to EHRs. These are the health IT core of your participation in pay-for-performance and other value-driven health care initiatives. Choose well.

Alistair Jackson, M.Ed.

Have you met the ARRA twins?

A few posts ago (see December 11, 2011), we looked at Transparency, the "big sister" of health care reform. Transparency raised her head again the other day, accompanied by a twin sister, Sunshine. The twin's full legal name is the Affordable Care Act, initials ACA. Quoting from the December 14, 2011 CMS press release, ACA is all about steps "designed to increase transparency in health care reform, which can lead to better care at lower costs."


The "sunshine" rule will be available as of December 19 here for fuller consideration. My purpose here is not to expound upon it rather to stress the pervasive nature of transparency as a control measure for both cost and quality in health care. 


Just yesterday, we saw an announcement out of HHS about dollar coins, reminding us of the Obama Administration’s Campaign to Cut Waste. The ACA "sunshine" rule is a variation on the same theme. When the sun shines on one, it shines on all. Without exception, transparency shines on eye care too. Every eye care provider will be accountable for the cost and quality of the care provided to patients. Payers and legislators may bring the hammer down but patients and consumers will be the jury. 


Alistair Jackson, M.Ed.

Stage 2 Certification – the Great Delay

By now, most of us know that Stage 2 Certification for EHRs is being delayed. Originally set to take effect January 1, 2013, it has been pushed back to 2014. This is a good thing for several reasons:

• Someone’s listening. We all want to be heard and there’s no shortage of input on this massive transformation in healthcare. The great delay is to give everyone the additional time they’re asking for. It’s a win-win response.
• Time is our friend. Health care reform is complex enough on a pure technology level. But it’s more than that. It involves all of us and our individual learning curves. In even the best case scenarios we need time to adapt and embrace.
• Incentive payments are unaffected. For those who started into their MU Attestation already – and even for those who will start in 2012 – the stimulus incentive grants are not affected. In fact, given that the Stage 2 and 3 requirements will only get more stringent, this means the early adopters get an easier ride. For a whole extra year, they get to keep doing what they’re already doing.*
• An early-adopter bonus. The incentive program rolls out over five years, right? Do the math. Those who got started in 2011 will finish collecting their grants by the end of 2015. That means the early adopters will finish collecting before Stage 3 hits. To be clear, I don’t mean Stage 3 standards will not apply to those who finish by 2015, only that they won’t have grant money at stake as they move into the Stage 3.

* This point is worth clarifying. I still get asked frequently if, once the 90-day Meaningful Use Attestation period is over, do I just wait until the next period comes around? The answer is no. The whole point of the incentive program is to get you engaged in permanent change. Your initial attestation period, be it in 2011, 2012 or later, will be 90 consecutive days. Once that period is over, you must continue demonstrating Meaningful Use 365 days a year, and from year to year. 

Alistair Jackson, M.Ed. 

Hares and turtles. So what about EHRs? (Part 2)

(Continued from Part 1)  So the rules have changed and now we’re expected to document differently. But wait, there’s more. It’s not just recording more results; it’s driving better care and improving patient outcomes. It’s about participating in all these new programs we keep hearing about. What does that look like and who’s counting? On top of all this, it’s also goodbye fee-for-service and hello pay-for-performance. Performance implies standards, right? What standards? That’s where the evidence base of medicine comes in.

So, we’re improving patient outcomes, measuring those improvements and getting paid only if standards of improvement are achieved, right? To make matters even more interesting, this new game must be played out not on Eye Care Island but at Connected Care Central. Episodal care is losing significance. Continuity of care spans both time and the multiplicity of Eligible Providers who comprise the patient’s care team.

Back to EHRs. We can begin to see why traditional EMRs won’t stand the test of time. Recording results electronically versus on paper is not a big enough step forward to make the difference. It’s like moving from a mechanical cash register to an electric one when we really need barcode scanners and RFIDs. We can change what we call them (from EMRs to EHRs) but if the new name amounts to new lipstick on the old pig, the old pig will nevertheless die.

EHRs that survive the long road to Meaningful Use will be those built specifically for health care reform, created with capabilities beyond recording results. In particular, we believe, the lines will be drawn over Clinical Decision Support. In stage 1, we’ve seen the topic introduced at a base level (structured data). In stages 2 and 3, this area will take off. It’s at that point we’ll see more dropouts from the health care reform game and the hares will be separated from the turtles.

Alistair Jackson, M.Ed.

Hares and turtles. So what about EHRs? (Part 1)

Sporting a subtitle like “Thought leadership in eye care EHRs” when I haven’t said anything yet about EHRs, it seems time to put my cards on the table.

 We’ve already seen a good few software vendors drop out of the race. The most obvious tell is those who just didn’t go for certification. They could see the bar rising and knew, for one reason or another, it was time to call it a day. That’s okay. They may prove to be the wise ones!

There are other groups too: let’s call them the turtles and the hares. The hares are those that raced to certification and got there first, for the most part the big-name players. That’s okay too. Several of these frontrunners were also the first to get the big surprise … that meaningful use had little to do with usability. One is for the feds and payers, the other is for you. Two audiences, two sets of criteria.

Then there are the turtles … you know, slow and steady wins the race? We turtles got the surprise too. It may have been slightly less rude. Even if you saw it coming, it still played out in the trenches with real users pushing back saying, “I don’t care if you’re certified, this isn’t working for me!” We’re all out of our comfort zone and it’s likely to stay that way for a while.                       

 There’s a hidden reality about this transition to EHRs. The obvious part is that we’re moving from paper to computers. What’s less obvious is that, even were we staying with paper, the rules would still be changing. The feds and payers are more in love with information than with technology. It’s just that Health IT is the means to the end. To control costs in healthcare, it takes more information, a lot more. As much as we feel unprepared for a higher level of documentation in EHRs, we’d be even less able to do it on paper. Imagine calculating those numerators and denominators on the back of your paper chart!

To be continued …

Alistair Jackson, M.Ed. 

Eye Care and the Million Hearts Initiative

The Million Hearts initiative is a great example of a new program in health care reform that really matters to ECPs. I wish I could tell you you’ll qualify to offer 20 counselling sessions per year for each of your patients who screens positive for obesity with a body mass index (BMI) ≥ 30 kg/m2. That role is restricted to PCPs.

Nevertheless, here’s takeaway for Eye Care Providers. As a user of certified EHRs, you must track vital signs including BMI. (As an ECP, you don’t have to weigh your patients. You can get vitals from other health records, from a Continuity of Care Document or Report, or you can ask the patient and record what he or she tells you.) 

ECPs engaged in the Million Hearts program by making referrals are establishing one more way to become valued members of the Patient-Centered Medical Home. PCMH teams will soon be given control over access to chronic care patients. Eligibility will be restricted to those Providers who are qualified to participate on chronic care teams. That qualification will formally include the ability to share health information electronically. This means EHRs and specifically EHRs that can communicate within the state’s Health Information Exchange (HIE). At an informal level perhaps, inclusion in the PCMH will require demonstrating value to the team. And that brings us full circle to being engaged in health care reform programs whether or not the ECP is eligible for direct funding.

So, if recording vitals seems like a waste of time and effort, let’s remember we are now players in a brand new game. The rules have changed. Health care is now connected care. As an ECP, your view of the patient is unique. You can add value to a care team by knowing the new rules and being ready to play. The future of your business depends on it.

Alistair Jackson, M.Ed. 

Health Care Reform – It’s about Transparency

Transparency is one of the most important concepts to understand in the transition to value-driven health care.  It directly affects how patients will perceive the care you provide. Note the following from the Health & Human Services web page.

“Transparency is a broad-scale initiative enabling consumers to compare the quality and price of health care services, so they can make informed choices among doctors and hospitals.

In cooperation with America’s largest employers and the medical profession, this initiative is laying the foundation for pooling and analyzing information about procedures, hospitals and physician services. When this data foundation is in place, regional health information alliances will turn the raw data into useful information for consumers.”

 That definition was written and published in 2007, perhaps earlier. When Dr. James Grue and I presented it, whether verbally or in writing, the response was often something like, “Well, that may be true for hospitals but it doesn’t apply to independent optometrists.” More ostrich syndrome!

 One of the most interesting and compelling examples of how precisely transparency applies to every optometrist in the country is seen on the Alabama BCBS website. Check out Find a Doctor. In Doctor Finder, choose Eye Doctor. Select a few doctors to compare. Now look at the tabs: Quality of Care; Surgeries & Procedures; Patient Satisfaction. Note also the Rating Compared to other BCBSAL Network Doctors.

 In professional baseball, we call these batting averages, published for all to see. Fans know where to find them. They memorize them and talk about them constantly among friends. Doctor, these areyour “batting” stats, published for your patients to see. And see them they will. The payers are making sure of that. You’ll note on the home page that big exclamation mark beside Understanding Healthcare Reform».

 And lest we think it’s only the Blues that are so engaged, current legislation requires Medicare to create a “Physician Compare” website modeled on the current website. This is Transparency and it’s not going away.

Alistair Jackson, M.Ed.

What are you doing about health care reform? (Part 2)

In Part 1, I pointed to a problem for Optometry as a whole, a shortfall of aggressive leadership in going after what Health Care Reform is all about. Health care is transforming. It’s a new game with all-new rules. With or without stimulus incentives and regardless of your Medicare or Medicaid volume, the new game in health care is about the survival of your business.

Let’s take for example the November publication by Blue Cross Blue Shield. Here is private insurance publicizing “What the Government Should Do”. Interesting, is it not, that CMS published its long-awaited Final Rule for Accountable Care Organizations (ACOs) only after the BCBS document had been officially released? There’s no longer room for the mentality that ARRA and HITECH don’t matter if you don’t do much Medicare. Sure, Medicare sits front and center but make no mistake: this is health care reform not Medicare reform and every payer, government or private, is getting in on the new game.

As called for by the federal reform law, the ACO program is intended to encourage networks of providers to collaborate on care for Medicare beneficiaries, with the aim of improving outcomes and reducing costs.  A key element in this agenda is the patient-entered medical home model, which will effectively control access to patients in order to ensure better outcomes and lower cost. Providers who are not embracing EHRs, not paying attention to their state-based HIEs and not engaged in the discussion about ACOs are losing ground on key “survive and thrive” issues that apply every bit as much to Eye Care Providers as to Primary Care Physicians.

Alistair Jackson, M.Ed. 

What are you doing about health care reform? (Part 1)

I recently asked that question of an optometrist I considered a prominent figure in the eye care profession. Response? “You know, I just don’t believe the feds are going to pull it off.” Unfortunately, that answer belies what I’ve heard all too often. Ostrich syndrome.
Meanwhile, our friends at HITECHAnswers (I strongly recommend following ) are announcing,“Critical Mass in the Advance of Health Information Technology” including:

• Over 115,000 eligible professionals have signed on with the Regional Extension Centers.
• Close to one billion dollars have been paid out in incentives to date. [aj: HHS has since announced, as of Oct.31, it was over $1.2 Billion.]
• Over 650 complete EHRs have received Stage 1 Certification.    
• 2012 will see the transition from the Temporary to the Permanent Certification Program. 

Optometry has a problem. Though far from all, too many leaders are playing wait ‘n see. Ophthalmology is not playing that game. Instead, the MDs are running away with the evidence-based medicine that will be critical to the Quality Measures upon which all eye care pay-for-performance will be established.
In our 2007 white paper, A White Paper for Optometry: Medicare Pay-for-Performance & Value-Driven Health Care, we asked the question, “Is it in the best interests of either the patient or the health care system itself to emphasize surgical and advanced-treatment methods over early intervention and preventive methods?” Then we gave our answer. “Clearly not! Yet this is the natural course of the current pay-for-performance implementation. Optometry must position itself to gain input into the outcomes selection process.”


Alistair Jackson, M.Ed. 

Did you say 200 million blogs?

Did you know that the Internet hosts over 200 million blogs? Better have something worthwhile to say, right? I’m glad you found your way to EMRlogic Live and promise to make your time with us thought provoking at least. My colleagues and I contend to be thought leaders in eye care EHRs for the health care reform era. We’ve taken what some call a revolutionary approach to EHRs. What does that mean? Why have we done it? This blog is about sharing where we believe we (and you) are going in eye care.

As we get launched here, a few things need to be acknowledged. One, you don’t need more news. You can go to Twitter for that. Two, you don’t need a sales guy masking as a blogger. Disclosure: I was a sales guy, for the past 10 years. I was also a teacher for 20 years before that. Today, I’m passionate about the dialog and the thinking around which you make decisions about your business. What I really want to do is challenge your thinking … in the hope you’ll make the best decisions for your eye care practice. Three, I’m not alone. While I’ll be the primary blogger, I won’t be writing as an island unto myself. Some of my colleagues are a lot smarter than I am, and I’ll be counting on their expertise. Dr. Jim Grue and Dr. Chuck Haine will be my two main SMEs but I’ll pull in others as well. And that includes you, of course, since the welcome mat is out for guest contributors and reply posts alike.